David Law is a Senior GP Partner in Bromsgrove
The NHS is struggling at present more than I have seen before in my twenty years in primary care. At my practice we strongly believe that Physician Associates (PAs) are part of the solution to the challenges we face and not part of the problem. I am concerned that much seems to have been said about PAs that appears ill-informed and to be coming from a standpoint of protectionism from my own profession – this does doctors no favours at all and risks further harming the high quality cares that we all want for our patients.
My context is a practice of about 13,000 patients in the market town of Bromsgrove, Worcestershire, where Sir Sajid Javid is currently our MP, and we are fortunate to have moved into an excellent purpose-built premises in 2011. There is a pleasant mix of demographics in an increasingly multicultural setting, though predominantly with English as a first language, with good schools and a road network that is efficient in all directions. It is a desirable place to live and work. Despite this there are times when we have struggled to recruit salaried doctors to join our equitable team. These times have mirrored what we read in the medical press of desperate struggles to recruit elsewhere.
We are a training practice in the North Worcestershire scheme taking a variety of specialist trainee and foundation years doctors and with our proximity to Birmingham have medical students from Years 1, 3 and 5. It was this educational enthusiasm that led to us being approached by the Physician Associate training programme at the University of Birmingham as potential hosts some 7 years ago. Whilst we didn’t feel we had capacity for further training we were able to be educated ourselves about this relatively new group of clinicians, hearing about science degree graduates now paying to put themselves through an intensive two-year training course with a view to passing a tough completion examination, including a therapeutics exam (in preparation for prescribing when regulated). Importantly they were not being trained in protocols but in the medical model of history-taking, examination and hypothesis forming that doctors utilise. Our attention turned to whether this highly motivated group might be able to help us serve our patients better in the face of our doctor recruitment struggles.
The practice has evolved its rota system over the years. With a growing administrative burden we briefly had a spell of taking pro-rata admin sessions, until a now retired colleague returned from one holiday having conceived of having an “On Call Admin Doctor” (OCAD). Bemused, we decided to give it a go and have been increasingly persuaded of the necessity ever since. Duties include dealing with all the blood results and incoming letters for clinicians not in practice by the end of the following working day, and used to also encompass medication reviews and repeat prescription signing before we recruited a prescribing pharmacist team. The OCAD name has stuck but the role could equally be named “Clinical Supervisor” these days to highlight the support that is offered to our trainee doctors, nurses, reception team and Physician Associate colleagues. Having a doctor without a clinical list means ready access for those needing timely advice to help with patient management – there are times when even senior colleagues will seek a quick check of the adequacy of a management plan in these days of increasingly complex patients.
We appointed our first Physician Associate, who came to us for her elective period prior to passing her final exams, but had also drawn attention from a long-qualified PA who was just starting teaching at the University, who joined us later that year also.
The availability of this supervision system placed us well to employ a Physician Associate and see how things went. We asked the Birmingham training programme to help us advertise a vacancy and to encourage their students demonstrating excellence, with a passion for working in general practice, to apply. We appointed our first Physician Associate, who came to us for her elective period prior to passing her final exams, but had also drawn attention from a long-qualified PA who was just starting teaching at the University, who joined us later that year also. Our OCAD signs all the prescriptions that the Physician Associate recommends which allows oversight of this aspect of management, as well as being able to review the notes of any and all of the patients on their list. In a very short amount of time we had all gained confidence in our new colleagues’ abilities to deal with an unfiltered general practice caseload. Patients also were giving us positive feedback about their interactionsDavid The Physician Associates rapidly localised to the practice’s methods and amused us with the report that recommended prescriptions were being tailored to their learned preferences of the different OCAD supervisors! In common with GP specialist trainees we began our Physician Associate recruits with longer appointment times and reduced these as their and our confidence grew. Naturally, the more newly qualified a Physician Associate is, the more time and supervision they will need. With time, adequate supervision and experience, PAs can work more autonomously, with some senior PAs joining in on-calls and working to 10-minute appointments. Indeed, these days we have a pay scale that allows for varying speeds of progression but encourages reaching the same consulting pattern as the doctors.
The experienced Physician Associate that we recruited is now one of our full-time partner colleagues at the practice, leads on QOF and mentors more junior Physician Associates in general practice within the local area on behalf of the Primary Care Network. We have had experience of four Physician Associates with three still employed and one who moved on after a period of maternity leave – they have all been excellent, hard-working colleagues with a passion for high quality patient care. We do not find our PA colleagues to be more risk averse than ourselves despite dealing with the same case mix. Until very recently, to remain practising they had to repeat their final examinations covering all the medical disciplines every five years. Their knowledge therefore often spurs us to review whether our own has become outdated. Fortunately, the art of caring for patients is a skill we all learn with added years of experience.
Having a doctor without a clinical list means ready access for those needing timely advice to help with patient management – there are times when even senior colleagues will seek a quick check of the adequacy of a management plan in these days of increasingly complex patients.
Many practices will be aware that the scarcity of doctors applying for roles has meant inflated salaries being offered to attract candidates. These inflated salaries cause the practice two problems – the first is that we believe that enhanced skills over time should mean that there is a differential income between newly qualified salaried doctors and GP Partners with years of experience. Without this differential there is much less incentive to take on management roles in addition to being a clinical provider. The high salaries requested threatened this ability to reward development and commitment in our practice; a practice which is keen to see all salaried clinical colleagues as having a view towards profit-sharing partnership. Secondly, high salary levels facilitates comfortable living on an ever lower number of sessions of work offered to the practice. This is thoroughly understandable as a method of protecting clinician wellbeing in the face of a system that threatens to overwork and overwhelm without great care. However smaller numbers of sessions worked inevitably means less possibility of continuity for patients and more shared administration requirements amongst clinicians. Our detailed clinical note-keeping aims to make team-working for patients as straightforward as possible, but adds time to consulting that was not required by previous GP generations.
Our Physician Associate colleagues are generally content to work eight-session weeks for us. They know that their pay scale is less than the doctors they work amongst and realise this is down to the route into clinical care that they have taken. As our PAs experience grows however this differential income ma Inclky be harder to justify, particularly if regulation eventually leads to independent prescribing and independent practice – where demonstrated skills justify this. Our PA Partner is working towards parity over a period of years, a period of time which we strongly hope will see the regulatory changes progress enough for her to become an independent clinician, a status for which it is clear she is more than capable.
We have found that the advent of PAs in general practice is of great benefit. Where a practice is appropriately configured to offer supervision then the number of clinical staff offering good patient access can be expanded further than is possible with a medical-only staff within existing budget constraints. This in turn means more clinicians to share workload, less clinician burnout and less need to keep reducing the sessional commitment it is possible to offer to the practice. Creating a realism for newly qualified GPs about salary expectations, which then incentivises high-quality candidates to prove themselves and progress to partnership-level responsibilities, is also welcomed if we want to sustain the independent contractor model which provides the autonomy of working arrangements which originally attracted many of us to practice.
My encouragement is that if, like me, you still hope to see the day where the NHS flourishes once again, and that the boast of the NHS being the envy of the world might hold more truth, then please embrace the colleagues joining us in general practice. Let us all work to the top of our trained abilities and together provide the quality and access that the public might reasonably expect.
Featured photo by Randy Fath on Unsplash
How to maximise profit and work less as a partner! RCGP is becoming expensively pointless.
had you asked many medical students or junior doctors how they feel about their jobs being taken by under qualified staff willing to work for less?
have you asked many of your patients about how they feel when they think they are seeing a doctor but it turns out that they are seeing someone who has just done a few months training?
Do your PAs make it ENTIRELY clear to patients that they are not medically or nursing qualified or do they just introduce themselves as ‘clinicians’
One practices experience is mildly interesting. It does not address safety issues of clinicians seeing patients with undifferentiated presentation across primary care, increased need for GP supervision, reduces patient access further for patients, PA are getting preferential technical training over doctors in training, and PA unlike nurses or paramedics, repeatedly not identifying themselves correctly to patients, especially as their training is the shortest of all clinicians. That pcn funding means practices are forced to employ non dr , who are less cost effective than GP.
I can absolutely see the attraction of employing PAs. Cheaper, and ostensibly able to see undifferentiated patients as a GP can.
It’s so concerning though to hear senior partners saying that PAs are no more averse to uncertainty than we are. Because they absolutely should be. Even a newly qualified GP has at least 10 years of studying and clinical experience. Most partners have had far longer, and a good deal of that time working with the same patients, the same systems and colleagues. A newly qualified PA has a 2 year crash course.
They can’t possibly know what they don’t know.
Your employing them, and saying that this is necessary to reset newly qualified GP salary expectations is insulting in the extreme, and devalues your own credibility. It’s ladder up-ism, I’m alright Jack, laughing all the way to the bank nonsense.
Very interesting and thoughtful read!! Thank you!